December 11, 2012

Unemployment poses a significant burden on the public no matter what the cause. But for those who have been diagnosed with a psychiatric illness, chronic unemployment is often coupled with significant health care costs. A Rhode Island Hospital study compared unemployment rates among those with various psychiatric disorders, and found that borderline personality disorder is associated with as much unemployment as bipolar disorder.

Researcher Mark Zimmerman, M.D., the director of outpatient psychiatry at Rhode Island Hospital, and his colleagues studied unemployment and disability rates in patients with bipolar disorder and depression with borderline personality disorder to determine the level of disability associated with each illness. The study is published in the December issue of the journal Bipolar Disorders.

Zimmerman found that depressed patients with borderline personality disorder were significantly more likely to have been persistently unemployed, as compared to patients with depression who do not have borderline personality disorder. When looking at patients with bipolar disorder, no distinct differences were found between those who have a co-morbid diagnosis of borderline personality disorder and those who do not.

"Bipolar disorder incurs a very high cost on patients, the mental health care system and society as compared to many other mental illnesses, and it is ranked as one of the leading causes of disability in the world," Zimmerman said. "Bipolar disorder often leads to profound disruptions at work and social functioning, and also carries with it an increased risk of suicide."

Previous studies in the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, led by Zimmerman, found that more than 80 percent of patients with bipolar disorder reported missing some time from work due to psychiatric reasons in the previous five years, and more than one third missed up to two years or more from work.

This study found that 29.6 percent of patients reported not missing any time from work in the past five years due to psychiatric illness, and 28 percent reported missing anywhere from a few days up to one month from work. Persistent unemployment, defined as missing up to two years or more from work, was present in 13.4 percent of patients, and 4.2 percent were chronically unemployed throughout the five-year period.

The study also found that depressed patients with borderline personality disorder significantly more often received disability payments at some time during the five-year period than depressed patients without the personality disorder.

"There has been a great deal of discussion about appropriate diagnosis of bipolar disorder, which has led to over diagnosis," Zimmerman said. "However, the over diagnosis of bipolar disorder has been to the neglect of borderline personality disorder diagnosis. Some bipolar disorder experts are calling for expansion of the disorder's diagnostic boundary, and this could lead to even more diagnoses of bipolar disorder. If this happens, there is cause for concern that those patients with borderline personality disorder will not be properly diagnosed or appropriately treated."

Both bipolar disorder and borderline personality disorder were associated with impaired job functioning and the ability to hold a job, and as such, carrying a significant public health burden. Efforts to improve detection of borderline personality disorder in depressed patients might be as important as the recognition of bipolar disorder.

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